What is the classification of this patient's cholecystitis according to the Tokyo Guidelines 2018 (TG18) and the American Society for Gastrointestinal Endoscopy (ASGE) classification?

Tokyo Guidelines 2018 (TG18) Classification of Acute Cholecystitis

The Tokyo Guidelines 2018 classifies acute cholecystitis into three severity grades (Grade I, II, and III) based on organ dysfunction and extent of gallbladder disease, which directly determines surgical timing and approach. 1

TG18 Severity Grading System

Grade I (Mild Acute Cholecystitis)

• No organ dysfunction present 2
• Limited disease confined to the gallbladder 2
• Cholecystectomy is considered a low-risk procedure 2
• Patients meet criteria of Charlson Comorbidity Index (CCI) ≤5 and ASA-PS ≤2 3
• Recommended treatment: Early laparoscopic cholecystectomy 3

Grade II (Moderate Acute Cholecystitis)

• No organ dysfunction but extensive gallbladder disease 2
• Makes cholecystectomy technically difficult to perform safely 2
• Characterized by:
  • Elevated white blood cell count 2
  • Palpable, tender mass in right upper quadrant 2
  • Disease duration >72 hours 2
  • Significant inflammatory changes on imaging 2
• Recommended treatment: Early laparoscopic cholecystectomy by experienced surgeons if CCI ≤5 and ASA-PS ≤2; otherwise medical treatment/gallbladder drainage followed by delayed cholecystectomy 3

Grade III (Severe Acute Cholecystitis)

• Defined by presence of organ dysfunction 2
• Historically considered mandatory for gallbladder drainage rather than immediate surgery 1
• TG18 revision: Selected Grade III patients can undergo laparoscopic cholecystectomy under strict criteria 1, 3:
  • Favorable organ system failure pattern 3
  • Negative predictive factors 3
  • CCI ≤3 and ASA-PS ≤2 3
  • Treatment at advanced center with experienced surgeons 3
• If not meeting strict criteria: Early/urgent biliary drainage followed by delayed cholecystectomy once condition improves 3

Diagnostic Criteria for Acute Cholecystitis

Diagnosis requires both local AND systemic signs of inflammation, confirmed by imaging 2:

Local Signs (One Required):

• Murphy's sign 2
• Mass, pain, or tenderness in right upper quadrant 2

Systemic Signs (One Required):

• Fever 2
• Elevated white blood cell count (neutrophil count shows strongest association) 1, 4
• Elevated C-reactive protein 1, 4

Imaging Confirmation:

• Right upper quadrant ultrasound (sensitivity 81%, specificity 83%) 4
• CT with IV contrast if ultrasound equivocal (sensitivity 92-93.4%) 4

Critical Clinical Implications

The TG18 represents a paradigm shift toward more aggressive surgical management, even in high-risk patients 1. The CHOCOLATE trial demonstrated that immediate laparoscopic cholecystectomy is superior to percutaneous drainage even in critically ill patients (APACHE 7-14), with only 5% complications versus 53% in the drainage group, and equivalent mortality 1.

For Grade II cholecystitis specifically, surgery within 72 hours significantly reduces: 5

• Difficulty dissecting Calot's triangle 5
• Conversion to open surgery 5
• Mean hospital length of stay 5
• Postoperative complications 5

ASGE Classification Note

The provided evidence does not contain ASGE-specific classification systems for cholecystitis or cholangitis. The ASGE primarily focuses on endoscopic management of biliary disease rather than severity grading systems. The Tokyo Guidelines remain the international standard for cholecystitis severity classification 1, 2, 3.

For acute cholangitis, severity assessment would require separate Tokyo Guidelines criteria (not detailed in the provided cholecystitis-focused evidence), which similarly stratify patients into Grade I (mild), Grade II (moderate), and Grade III (severe) based on organ dysfunction and response to initial treatment 1.